Healthcare Provider Details

I. General information

NPI: 1851670079
Provider Name (Legal Business Name): SOUTHEAST PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 S VAL VISTA DR STE 161
GILBERT AZ
85295-1680
US

IV. Provider business mailing address

2730 S VAL VISTA DR STE 161
GILBERT AZ
85295-1680
US

V. Phone/Fax

Practice location:
  • Phone: 480-857-6316
  • Fax: 480-857-6638
Mailing address:
  • Phone: 480-857-6316
  • Fax: 480-857-6638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KHALID HASAN
Title or Position: OWNER
Credential: M.D.
Phone: 480-857-6316